7 acc prevention other cv therapies
Upcoming SlideShare
Loading in...5
×
 

7 acc prevention other cv therapies

on

  • 562 views

ACC Prevention Other CV Therapies

ACC Prevention Other CV Therapies

Statistics

Views

Total Views
562
Views on SlideShare
562
Embed Views
0

Actions

Likes
0
Downloads
0
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • This study of 286,383 community-dwelling members (>65 years of age) in 3 large managed-care organizations evaluated the effect of influenza vaccination during the 1998-1999 and 1999-2000 flu seasons. The results from the 1998-1999 season are shown on this slide. Influenza vaccination in adults >65 years was associated with a decreased risk of hospitalization for cerebrovascular disease and heart disease, as well as, a decreased risk of death from all causes. <br />
  • Aldosterone acts within the distal tubule of the kidney to promote sodium and water retention, as well as, potassium and magnesium excretion. Aldosterone also acts within the CV system to promote myocardial and vascular fibrosis. Aldosterone antagonists, such as spironolactone and eplerenone, inhibit these undesirable effects. <br />
  • The RALES trial was one of the first large randomized studies to evaluate the effect of neurohormonal modulation on top of ACE inhibition in patients with symptomatic, moderate to severe heart failure. The trial was stopped early because of a significant reduction in all cause mortality with spironolactone. Patients on spironolactone also had a significant 35% relative risk reduction in hospitalization for worsening heart failure, as well as, significant improvement in NYHA classification. <br />
  • The EPHESUS trial specifically sought to evaluate aldosterone inhibition in patients with heart failure and left ventricular systolic dysfunction (EF 6.6mmol/L) in the eplerenone group. <br />
  • Digitalis inhibits Na+/K+ ATPase leading to an increase in intracellular sodium concentration. This results in accumulation of intracellular calcium in the heart via the Na+/Ca++ channel. Increased intracellular calcium promotes calcium release by the sarcoplasmic reticulum that binds troponin-C, leading to increased contractility. Digitalis also increases vagal activity, resulting in reduced chronotropy (heart rate) and dromotropy (conduction velocity). <br />
  • The Digitalis Investigation Group trial randomized 6,800 patients with an EF &lt;0.001). <br />
  • Patients with an EF &lt;30% and an ischemic cardiomyopathy have a reduced risk of sudden cardiac death with an ICD. Whether additional parameters may be useful in better risk stratifying those individuals most likely to benefit from an ICD remains to be determined. <br />
  • This slide provides an algorithm to guide decision-making regarding the use of an implantable cardioverter defibrillator (ICD) in patients greater than 1 month following a myocardial infarction. If the ejection fraction remains 40%, an ICD is not indicated. For patients with an ejection fraction between 31-40%, an ICD may be indicated if there are additional markers of electrical instability. An electrophysiology study is then indicated to assess for inducibility of ventricular arrhythmias. <br />
  • This slide shows data from the Duke Databank for Cardiovascular Disease from 1995-2002 and demonstrates the increased use of aspirin, beta-blockers, and lipid-lowering agents in patients with CAD and the increased use of ACE inhibitors in patients with CAD + heart failure. While use of these effective therapies has increased, there is still room for improvement <br />
  • Blood pressure awareness, treatment, and control rates have improved little over the past two decades. <br />
  • This slide shows the prevalence of antihypertensive medication use among adults during 1998-1994 and 1999-2002. The use of antihypertensive medications increased from 57% to 63%. Use of more than one antihypertensive medication increased from 29% to 36%. Diuretics were the the most commonly used drugs during both time periods. <br />
  • Adherence to statin therapy continues to be a major obstacle in the treatment of patients with coronary artery disease. <br />
  • Based on data from the National Health and Nutrition Examination Survey, two thirds (66.3%) of adults have met their Adult Treatment Panel III-defined LDL-C goal. Of those at high and very high risk, however, only 23% and 26%, respectively, have met their LDL-C goal of &lt;100 mg/dL. <br />
  • Despite the large body of evidence supporting improved control of HbA1c, blood pressure, and cholesterol levels in patients with diabetes mellitus, desired goals are infrequently achieved. In the NHANES period from 1999-2000 (NHANES IV), 37% achieved the target HgA1c &lt;200 mg/dL. Only 7% met all three target goals. <br />
  • This data comes from 237,225 patients enrolled in the Get With the Guidelines-CAD program that were hospitalized between 2002-2007. Six quality measures were evaluated in eligible patients without contraindication: aspirin at admission and discharge, beta-blocker use at discharge, ACE inhibitor or angiotensin receptor blocker use, lipid-lowering medication use, and tobacco cessation counseling. Over time, utilization of these 6 measures increased from 86.5% to 97.4% (+10.9%) in men and 84.8% to 96.2% (+11.4%) in women. This slight difference in utilization by sex remained significant over time (P75 years), utilization increased from 87.1% to 97.7% (+10.6%) and from 83.0% to 95.1% (+12.1%), respectively. <br />
  • The American Heart Association’s Guidelines Applied in Practice (GAP) program for the management of patients with acute myocardial infarction (GAP) followed 2,857 patients in 33 Michigan hospitals. The program compared patient care before and after implementation of GAP. The GAP initiative focused on changes in the use of evidence-based therapies, adoption of standardized admission and discharge tools, and effects on mortality. <br /> As shown on the slide, after the inception of the GAP initiative, there were significantly lower rates of in-hospital mortality (P=0.017), 30-day mortality (P=0.001), and 1-year mortality (P=0.004). <br />
  • This data comes from the GRACE registry between 1999-2005. Among patients with a ST-segment elevation myocardial infarction, there was greater utilization of a beta-blocker (+11%, 95% CI 7.6-14), statin (+48%, 95% CI 45-52), and ACE inhibitor or angiotensin receptor blocker (+22%, 95% CI 18-25) over time. This resulted in significant reductions in new onset heart failure, stroke, myocardial infarction, and death at 6 months. <br />
  • The Cardiac Hospital Atherosclerosis Management Program (CHAMP) focused on initiation of evidence-based therapies prior to hospital discharge in patients with CAD. Clinical event rates were compared in the 256 pre-CHAMP and 301 post-CHAMP patients in the first year after hospital discharge for AMI. <br /> The increased use of aspirin, beta blockers, ACE inhibitors, and statins as a result of the CHAMP initiative led to a marked reduction in nonfatal MI and all-cause mortality. At one year, recurrent myocardial infarction was reduced from 8% to 3% (P&lt;0.05). <br /> This study confirms that improved use of evidence–based therapies translates into reduced cardiovascular events and improved survival. <br />
  • This analysis is part of the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) registry and includes nearly 65,000 patients. As shown above, greater compliance with overall guideline recommendations results in lower in-hospital mortality. <br />
  • This data comes from the GRACE registry between 1999-2005. Among patients with a non-ST-segment elevation myocardial infarction, there was greater utilization of a beta-blocker (+10%, 95% CI 7.5-12), statin (+42%, 95% CI 40-45), and ACE inhibitor or angiotensin receptor blocker (+23%, 95% CI 20-26) over time. This resulted in significant reductions in new onset heart failure, stroke, myocardial infarction, and death at 6 months. <br />
  • The Federal Study of Adherence to Medications in the Elderly (FAME) sought to determine whether a pharmacy intervention program could improve medication adherence among an older community-based population with cardiovascular risk factors. A total of 200 patients >65 years of age on a mean of 9 chronic medications underwent a 2 month run-in phase. A majority of patients had drug-treated hypertension (91.5%) and drug-treated dyslipidemia (80.6%). <br /> Thereafter, all individuals underwent a 6 month intervention phase with standardized medication education, regular follow-up by pharmacists, and dispensing of medications in time-specific blister packs. This was followed by a 6 month randomized phase of continued pharmacy intervention vs. usual care. The primary end point was a between-group comparison of medication use. <br /> Baseline medication adherence was 61.2%. After 6 months of intervention, medication adherence increased to 96.9% and was associated with significant improvements in systolic blood pressure (133.2 [14.9] to 129.9 [16.0] mm Hg; P = .02) and levels of LDL-C (91.7 [26.1] to 86.8 [23.4] mg/dL; P = .001). Six months after randomization, medication adherence decreased to 69.1% among those receiving usual care and was sustained at 95.5% in those receiving pharmacy intervention (P&lt;.001). This was associated with significant reductions in systolic BP in the pharmacy care group (–6.9 mm Hg; 95% CI, –10.7 to –3.1 mm Hg) vs. the usual care group (–1.0 mm Hg; 95% CI, –5.9 to 3.9 mm Hg; P = .04), but no significant between-group differences in LDL-C levels. <br />

7 acc prevention other cv therapies 7 acc prevention other cv therapies Presentation Transcript

  • The Evidence for Current Cardiovascular Disease Prevention Guidelines: Other Cardiovascular Therapies American College of Cardiology and Practice Quality Initiative Areas with Best Subcommittee and for Improvement Room Prevention Committee
  • Classification of Recommendations and Levels of Evidence *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. †In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.
  • Icons Representing the Classification and Evidence Levels for Recommendations I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III
  • Evidence for Current Cardiovascular Disease Prevention Guidelines Vaccination Evidence and Guidelines
  • Influenza Vaccination: Primary Prevention 286,383 community-dwelling members aged >65 years of 3 large managedcare organizations evaluated for 1-2 yrs Adverse Outcome Vaccinated Subjects (N=77,738) Unvaccinated Adjusted Subjects Odds Ratio (N=62,317) Hospitalization for CHD 457 (0.6) 535 (0.9) 0.80 0.001 Hospitalization for HF 466 (0.6) 538 (0.9) 0.81 0.002 Hospitalization for CVD 398 (0.5) 427 (0.7) 0.84 0.018 Death 943 (1.2) 1361 (2.2) 0.52 <0.001 Hospitalization or death 2387 (3.1) 2910 (4.7) 0.65 <0.001 P value Influenza vaccination reduces the rate of adverse CV events CV=Cardiovascular Source: Nichol KL et al. NEJM 2003;348:1322-1332
  • ADA Immunization Recommendations for Patients with Diabetes Mellitus Primary Prevention • An influenza vaccine should be provided to all diabetic patients >6 months of age annually. • A pneumococcal polysaccharide vaccine should be administered to all diabetic patients >2 years of age. A one-time revaccination is recommended for individuals >64 years of age that were previously immunized at <65 years of age, if the vaccine was administered >5 years ago. Other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation. ADA=American Diabetes Association Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
  • Influenza Vaccination Guidelines I IIa IIb III Secondary Prevention Patients with cardiovascular disease should have an annual influenza vaccination Source: Smith Jr SC et al. JACC 2011;58:2432-2446
  • Evidence for Current Cardiovascular Disease Prevention Guidelines Ejection Fraction Evidence and Guidelines
  • Relationship Between Ejection Fraction Post Myocardial Infarction and Mortality 1,181 patients with myocardial infarction treated with fibrinolytic therapy that underwent SPECT and RNA to evaluate LV EF LV EF assessed after MI is predictive of mortality at 6 months LV EF=Left ventricular ejection fraction, MI=Myocardial infarction, RNA=Radionuclide angiography, SPECT=Single photon emission computed tomography Source: Burns RJ et al. JACC 2002;39:30-36
  • Ejection Fraction Guidelines Secondary Prevention I IIa IIb III Echocardiography in those following a STEMI to re-evaluate ventricular function when results are used to guide treatment† Echocardiography or radionuclide angiography in those following a NSTE-ACS when results are used to guide treatment‡ NSTE-ACS=Non-ST-segment elevation acute coronary syndrome, STEMI=ST-segment elevation myocardial infarction Sources: Antman EM et al. JACC 2004;44:671-719 ‡ Anderson JL et al. JACC 2007;50:652-726 †
  • Evidence for Current Cardiovascular Disease Prevention Guidelines Aldosterone Antagonist Evidence and Guidelines
  • Aldosterone Antagonist: Mechanisms of Action Aldosterone Sodium and Water Retention Edema Potassium and Magnesium Excretion Arrhythmias Collagen deposition Myocardial and Vascular Fibrosis
  • Aldosterone Antagonist: Secondary Prevention Randomized Aldactone Evaluation Study (RALES) 1,663 patients with NYHA Class III or IV HF and LVSD (EF <0.35) randomized to spironolactone (25-50mg) or placebo for 24 months Survival (%) 1.00 .90 .80 .70 Spironolactone .60 .50 Placebo RR = 0.70, P<0.001 0 0 3 6 9 12 15 18 21 24 27 30 33 36 Months Aldosterone inhibition improves survival in patients with advanced heart failure EF=Ejection fraction, HF=Heart failure, LVSD=Left ventricular systolic dysfunction, NYHA=New York Heart Association Source: Pitt B et al. NEJM 1999;341:709-717
  • Aldosterone Antagonist: Secondary Prevention Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) All Cause Mortality (%) 3,313 patients with evidence of HF and LVSD (EF <0.40) after a MI randomized to eplerenone (25-50 mg) or placebo for 16 months 25 Placebo 20 Eplerenone 15 10 5 0 RR = 0.85, P=0.008 0 6 12 18 Month 24 30 36 Aldosterone inhibition improves survival in patients with post-MI HF and LVSD EF=Ejection fraction, LVSD=Left ventricular systolic dysfunction, MI=Myocardial infarction, HF=Heart failure Source: Pitt B et al. NEJM 2003;348:1309-1321
  • Aldosterone Antagonist: Secondary Prevention Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) 2737 patients with NYHA Class II HF symptoms and LVSD (mean LV EF 26%) randomized to eplerenone (25-50 mg) or placebo for a median of 21 months* 10 100 Eplerenone % 50 % 5 18.3 Placebo 25.9 0 Primary endpoint** 12.5 15.5 0 All-cause mortality Aldosterone inhibition improves survival in patients with mild HF and LVSD *The study was stopped prematurely **Composite of CV death or hospitalization for HF CV=Cardiovascular, EF=Ejection fraction, HF=Heart failure, LVSD=Left ventricular systolic dysfunction, NYHA=New York Heart Association Source: Zannad F et al. NEJM 2011;364:11-21
  • Aldosterone Antagonist Guidelines Secondary Prevention I IIa IIb III Use of aldosterone blockade in post-MI patients without significant renal dysfunction* or hyperkalemia** is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta-blocker, who have a LV EF <40%, and who have either DM or HF *Estimated creatinine clearance should be >30 ml/min **Potassium should be <5.0 mEq/L ACE=Angiotensin converting enzyme, DM=Diabetes mellitus, EF=Ejection fraction, HF=Heart failure, LV=Left ventricular, MI=Myocardial infarction Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
  • Evidence for Current Cardiovascular Disease Prevention Guidelines Digoxin Evidence and Guidelines
  • Digoxin: Mechanism of Action Digoxin Na-K ATPase Na+ K+ Na-Ca Exchange Na+ Ca++ Myofilaments K + Na Ca++ + Contractility
  • Digoxin: Secondary Prevention Digitalis Investigation Group (DIG) Trial 6,800 patients with LV systolic dysfunction (EF <45%) randomized to digitalis (0.25 mg) or placebo for 37 months Placebo Digitalis HR=0.75, P<0.001 Digitalis reduces the rate of hospitalization for heart failure* *28% relative risk reduction (p<0.001) Source: Digitalis Investigation Group. NEJM 1997;336:525-533
  • Digoxin Guidelines I IIa IIb III Secondary Prevention Digoxin in those with symptomatic HF and LVSD (EF <45%) to reduce hospitalizations for HF* I IIa IIb III Digoxin in those with asymptomatic LVSD and normal sinus rhythm *Contraindications include significant sinus or atrioventricular block unless a permanent pacemaker is present EF=Ejection fraction, HF=Heart failure, LVSD=Left ventricular systolic function Source: Hunt SA et al. Circulation 2005;112:e154-235
  • Evidence for Current Cardiovascular Disease Prevention Guidelines Implantable Cardioverter Defibrillator Evidence and Guidelines
  • % mortality reduction with ICD Implantable Cardioverter Defibrillator: Secondary Prevention 80 60 75% 73% Overall death Arrhythmic death 61% 54% 55% 40 31% 20 0 MADIT1 MUSTT2 MADIT-II3 27 Months EF <35% 39 Months EF <40% 20 Months EF <30% *Primary prevention of sudden cardiac death Sources: Moss AJ et al. NEJM 1996;335:1933-1940 2 Buxton AE et al. NEJM 1999;341:1882-1890 3 Moss AF et al. NEJM 2002;346:877-883 1
  • Implantable Cardioverter Defibrillator: Algorithm in Secondary Prevention At least one month following MI EF < 30% EF 31-40% Yes + EPS EF > 40% No - No ICD Medical Rx EF=Ejection fraction, EPS=Electrophysiology study, ICD=Implantable cardioverter defibrillator, Rx=Treatment Source: DiMarco JP et al. NEJM 2003;349:1836-1847
  • Implantable Cardioverter Defibrillator Guidelines Secondary Prevention I IIa IIb III Patients with an ejection fraction of <35% who are at least 40 days post-MI and are in NYHA functional Class II or III Patients with an ejection fraction of <30% who are at least 40 days post-MI and are in NYHA functional Class I I IIa IIb III Patients with nonsustained VT due to prior MI, an ejection fraction of <40%, and inducible sustained VT or VF at EP study EP=Electrophysiology, MI=Myocardial infarction, NYHA=New York Heart Association, VF=Ventricular fibrillation, VT=Ventricular tachycardia Epstein AE et al. Circulation 2008;117:e350-408
  • Evidence for Current Cardiovascular Disease Prevention Guidelines Room for Improvement
  • Utilization of Risk Reducing Medications at Discharge in Acute Coronary Syndromes ACTION Registry/Get With The Guidelines (GWTG) Data 100% 99% 97% 97% 95% 88% 94% 83% 88% 80% 86% 72% 60% NSTEMI STEMI 40% 20% 0% ASA Beta Blockers ACE-1 or ARB Statins Clopidogrel NSTEMI=Non-ST-segment elevation myocardial infarction, STEMI=ST-segment elevation myocardial infarction Source: ACTION Registry-GWTG DATA: January 1, 2010 – December 31, 2010. Courtesy of NCDR 10/21/2011
  • Self-Reported Medications in Patients with Coronary Artery Disease + Heart Failure Duke Databank for Cardiovascular Disease* *n=31,750 ASA=Aspirin, ACE-I=Angiotensin converting enzyme inhibitor, BB=Beta-blocker, CAD=Coronary artery disease, CHF=Congestive heart failure, HF=Heart failure Source: Newby LK et al. Circulation 2006;113:203-212
  • Hypertension Awareness, Treatment, and Control in the United States National Health and Nutrition Examination Survey (NHANES) 80 % Adults 60 40 73% 51% 31% 55% 68% 70% Awareness 59% Treatment 54% 34% Control 29% 27% NHANES II NHANES III NHANES III NHANES 1976-1980 (Phase 1) 1988-1991 (Phase 2) 1991-1994 1999-2000 20 10% 0 Source: Chobanian AV et al. JAMA 2003;289:2560-2572
  • Antihypertensive Drug Use in the United States National Health and Nutrition Examination Survey (NHANES) ACE=Angiotensin converting enzyme Source: Gu Q et al. Circulation 2006;113:213-221
  • HMG-CoA Reductase Inhibitor: Adherence to Therapy 100 Acute Coronary Syndrome n=22379 80 60 Primary Prevention 40 ) % e a R ec ne ehd A ( t r Coronary Artery Disease n=85020 n=36106 20 0 0 3 6 9 12 15 18 21 24 Months Source: Jackevicius CA et al. JAMA 2002;288:462-467
  • Cholesterol Treatment Gap in the United States National Health and Nutrition Examination Survey (NHANES)* *Based on 7,399 subjects in NHANES from 1999-2002 Keevil JG et al. Circulation 2007;115:1363-1370
  • Achievement of Risk Factor Goals Among Diabetics in the United States (%) National Health and Nutrition Examination Survey (NHANES) 100 90 80 70 60 50 40 30 20 10 0 NHANES III HbA1c<7% BP <130/80 mm Hg NHANES IV TC <200 mg/dL Good Control of all 3 BP=Blood pressure, DM=Diabetes mellitus, HbA1C=Glycosylated hemoglobin, TC=Total cholesterol Saydah S et al. JAMA 2004;291:335-342
  • Utilization of Risk Reducing Interventions at Discharge in Acute Coronary Syndromes ACTION Registry/Get With The Guidelines (GWTG) Data 100% 80% 60% NSTEMI 40% STEMI 20% 0% Exercise Counseling Dietary Cardiac Rehab Modification Referral Smoking Cessation NSTEMI=Non-ST-segment elevation myocardial infarction, STEMI=ST-segment elevation myocardial infarction ACTION Registry-GWTG DATA: January 1, 2010 – December 31, 2010. Courtesy of NCDR 10/21/2011
  • Evidence for Current Cardiovascular Disease Prevention Guidelines Quality Improvement Initiatives
  • Strategies for Initiating and Optimizing Cardiovascular Therapies • Hospital based performance improvement systems • In-hospital initiation of CV protective therapies • Pay for performance/financial incentives • Nurse or pharmacist managed outpatient CV prevention programs • Preventive cardiology and cardiac rehabilitation centers • Virtual prevention clinics using electronic medical record systems • Combination of CV protective medications CV=Cardiovascular
  • Utilization of Risk Reducing Therapies in Coronary Artery Disease Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) ec ner ehda t necr e P Composite performance measure adherence by age and gender Quarters of participation Lewis WR et al. Circ Cardiovasc Qual Outcomes 2009;2:633-641
  • Utilization of Risk Reducing Therapies After Acute Myocardial Infarction Guidelines Applied in Practice (GAP) Initiative 45 40 Mortality (%) 35 Baseline Post-GAP P=0.004 30 P=0.001 25 20 15 P=0.017 10 5 0 In-hospital Mortality 30-day Mortality 1-yr Mortality MI=Myocardial infarction Eagle KA et al. JACC 2005;46:1242-1248
  • Utilization of Risk Reducing Therapies After ST-Segment Elevation Myocardial Infarction Registry of Acute Coronary Events (GRACE) Global % Patients Registry of 4,608 patients with a ST-segment elevation myocardial infarction Fox KAA et al. JAMA 2007;297:1892-1900
  • Utilization of Risk Reducing Therapies After Non-ST-Segment Elevation ACS Cardiac Hospital Atherosclerosis Management Program (CHAMP) 14.8 15 Pre-CHAMP* Post-CHAMP* 10 7.8 7.6† 7.0 %, et a Rt nev E 4.7 5 3.1† 3.3† 2.6 0 Recurrent MI Heart Failure Hospitalization Total Mortality *1 year outcomes † P<0.05 ACS=Acute coronary syndrome, MI=Myocardial infarction Fonarow GC et al. Am J Cardiol 2001;87:819-822
  • Utilization of Risk Reducing Therapies After Non-ST-Segment Elevation ACS Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) Registry NSTE-ACS 7 6 5 4 3 2 1 0 8 In-Hospital Mortality, % In-Hospital Mortality, % 8 1 2 3 4 Hospital Composite Guideline Adherence Quartiles NSTE-MI 7 6 5 4 3 2 1 0 1 2 3 4 Hospital Composite Guideline Adherence Quartiles NSTE-ACS=Non-ST-segment elevation acute coronary syndrome, NSTE-MI=Non-ST segment elevation myocardial infarction Peterson ED et al. JAMA 2006;295:1912-1920
  • Utilization of Risk Reducing Therapies After Non-ST-Segment Elevation ACS Global Registry of Acute Coronary Events (GRACE) Registry of 8,375 patients with a non-ST-segment elevation ACS ACS=Acute coronary syndrome Fox KAA et al. JAMA 2007;297:1892-1900
  • Pharmacy Intervention to Improve Utilization of Risk Reducing Therapies Federal Study of Adherence to Medications in the Elderly (FAME) 200 patients with CV risk factors randomized to pharmacy intervention* or usual care for 6 months An intervention program significantly improves adherence *Includes standardized medication education, regular follow-up by pharmacists, and medications dispensed in time-specific blister packs CV=Cardiovascular Lee JK et al. JAMA 2006;296:2563-2571